Background
Malaria is the leading cause of death in children in Africa [
1]. In 2015, there were 429,000 malaria-associated deaths in the world and most of these deaths (92%) occurred in sub-Saharan Africa [
1]. Pregnant women living in endemic areas are among the most vulnerable to malaria infection [
2,
3]. Infection with
Plasmodium falciparum during pregnancy is responsible for intra-uterine growth retardation which can lead to low birth weight and early infant death [
3‐
6].
Currently, for malaria endemic areas, the World Health Organization (WHO) recommends a package of prevention methods to reduce morbidity and mortality associated with the disease [
6]. Among pregnant women, the core preventive interventions are vector control through the provision and use of insecticide-treated bed nets (ITNs) and intermittent preventive treatment during pregnancy (IPTp) to prevent pregnancy-associated malaria (PAM) [
6]. The combination of both prevention strategies has been found to be cost-effective and is associated with substantial reduction in neonatal mortality and low birth weight [
7‐
9].
Senegal is one of the 43 sub-Saharan countries where malaria is endemic and represents one of the leading causes of childhood mortality and negative birth outcomes. However, average parasitaemia among children under five was 5.7% in 2008 and felt to 2.9% in 2010–2011 [
10]. Between 2005 and 2008–2009, all-cause under-five mortality dropped from 121 to 72 deaths per 1000 live births [
11,
12]. Additionally, decline of the number of malaria cases was observed after the nationwide implementation of rapid diagnostic test (RDTs) and treatment of malaria episodes with artemisinin-based combination therapy (ACT). Use of ITNs has been shown to reduce malaria incidence rate by 50% and mortality rates by 55% in children under 5 years in sub-Saharan Africa [
13]. Senegal started the distribution of ITNs among children and pregnant women in 2003 and since 2011, the nationwide distribution of ITNs is extended to the general population [
14] through different channels, such as health centres, community-based organizations, schools, and social marketing activities. In 2016, there was a nationwide distribution campaign in Senegal that resulted to more than 8 million ITNs being distributed across the country [
15].
In addition to ITNs, IPTp with sulfadoxine–pyrimethamine (SP) has been shown to be an effective method of preventing malaria in pregnancy. The WHO recommends that IPTp-SP should be given at each scheduled antenatal care visit, starting as early as possible during the second trimester [
9]. Since 2003, IPTp-SP has been available at no cost at all the public health facilities in Senegal. Following WHO recommendations in 2013, the country has transitioned from the standard 2-dose regimen to the three dose IPTp regimen, beginning in the second trimester and with treatments spaced at least 1 month apart intervals [
15,
16].
In working to achieve malaria elimination, the NMCP in Senegal has outlined ambitious goals with a target of 80% of all pregnant women using ITNs and at least 80% receiving IPTp to move Senegal toward the goal of pre-elimination by 2020 [
15]. There has been no recent study [
17] conducted on use of malaria preventative measures in pregnant women in Senegal using a nationally representative dataset such as the Demographic and Health Survey. In this context, this study used a nationally representative dataset to investigate the factors contributing to the suboptimal uptake of prevention measures (IPTp and ITNs) among women with a recent pregnancy in Senegal to better understand the factors that might improve the implementation and scale-up of malaria prevention methods during pregnancy and to meet national and international targets.
Discussion
In Senegal, malaria represents a serious public health threat and a leading cause of mortality among children under 5 years of age. The Senegalese National Malaria Control Programme (NMCP) Strategic Plan has set ambitious malaria pre-elimination goals aiming to reduce malaria related mortality to a level close to zero by 2020 [
15]. In this context, there is a need to understand factors that influence suboptimal uptake of malaria prevention methods in high-risk groups such as pregnant women. In this study, the effect of different variables on the uptake of malaria prevention methods (IPTp and ITNs) were investigated from a nationally representative dataset. The results of this study show that less than half (< 50%) of women with a recent pregnancy reported use of both IPTp and ITNs during their last pregnancy and nearly half of the participants reported partial use (either IPTp or ITNs) during their last pregnancy. Despite governmental and international donor efforts, the target set by the NMCP and President’s Malaria Initiative of at least 80% ITN coverage in the population and least 80% coverage of IPTp among pregnant women in Senegal has yet to be achieved [
12].
While the results of this study reveal that the Senegal has yet to achieve the target described within the National Strategic Plan against malaria [
15], the level of uptake of IPTp and ITNs in Senegal are higher in the DHS 2013–2014 compared to previous years according to the results of successive Demographic and Health Surveys: in 2009, the use of IPTp was 12%, and in 2010 it increased to 39% [
25]. This finding of lower than target uptake of IPTp and ITNs is in contrast to the high antenatal clinic attendance rate of > 90% nationally. As such, this study confirms similar studies in sub-Saharan Africa which demonstrate a large discordance between frequency of antenatal care visit attendance and use of malaria prevention methods [
26,
27]. Since IPTp and ITNs should be given free during antenatal care visits, a possible explanation of the discrepancy between high ANC coverage and suboptimal use of malaria prevention methods is the occurrence of drug or net stock-out at the district or regional level [
3]. Additionally, although this study did not specifically look at the provider of the health care system, the huge gap between the rate of antenatal care and the optimal use of malaria prevention methods suggests that there might be other factors related to delivery at the health care facility as well as socioeconomic and individual behavior factors [
28‐
30]. This may suggest the training with more formative supervision of provider practices in the delivery of protective measures against malaria alongside with increasing health promotion activities at the community level on the importance of mothers’ use of IPTp and ITNs [
31]. Similar studies in sub-Saharan Africa have demonstrated poor adherence of health workers to provision of IPTp and training them with simplified IPTp messages may be a key strategy in malaria control programme targeting malaria prevention in pregnancy [
32,
33]. Previous studies have shown that health care worker training to increase awareness on the importance of ANC attendance are key factors affecting the delivery, access, and use of interventions to prevent malaria in pregnancy in sub-Saharan Africa [
30]. Such approaches are planned as part of the NMCP’s “IPTp relaunch plan,” in an effort to maximize ANC visits as opportunities for malaria prevention in pregnancy.
There were large discrepancies between uptake of optimal malaria prevention methods by region. These findings reflect more geographical differences and disparities in the uptake of malaria prevention methods during pregnancy as women living in the regions like Matam, Thies, Louga, Fatick, Diourbel and Saint-Louis were more likely to use optimal prevention methods compared to pregnant women in Dakar. The discrepancies between regions may reflect inequities into access to health care. Place of residence has been previously associated with discrepancies in access and utilization of health care prevention programmes, such as malaria and tuberculosis programmes [20-37-38]. This situation might be explained by the level to which the policies regarding free distribution of IPTp and ITNs have been implemented across the country, especially in the rural areas, but less so in affluent Dakar. Additionally, it is also possible that in some regions, particularly in the rural South of Senegal, due to different factors (level of malaria transmission, rainfall, and efficacy of malaria case management in the health services) women might be more likely to use malaria prevention methods compared to women living in Dakar, the urban capital city of Senegal [
33]. The findings from this study are similar to a study in Ethiopia who found an association between the type of place of residence and ITN usage among pregnant women [
34].
Women aged 35–49 years were more likely to make use of optimal prevention methods during pregnancy compared to women younger than 20 years of age. This observation may be because young adolescent women are least likely to have a prior pregnancy and are less likely to have previously received information and malaria prevention methods. Further, older women have more knowledge and experience regarding pregnancy and risk of malaria and may, therefore, be more likely to use preventive measures during pregnancy.
Additionally, women classified in the middle wealth quintile were more likely to use malaria protection than women classified in the poorest quintile. These data suggest that even with scale-up of malaria control interventions, present distribution strategies are still not reaching the needs of some of the most vulnerable groups, including the poor. The fact that women from poorer households are disadvantaged in the context of free distribution of IPTp and ITNs [
3,
17,
28‐
33,
35] has been previously documented in studies from Kenya, Senegal and Uganda. In a previous study from DHS data in Senegal, Faye et al. [
17] showed that the fact that women have to pay in order to have access to health care centre (where they would receive the freely distributed IPTp and ITN) can negatively impact their access to a health service interventions and tools for malaria prevention in Senegal [
17]. Women from poorer households may be faced with long queues at antenatal clinics, as well as transport costs, the ticket to the entry to the clinics which may hinder their access to the freely administered IPTp and ITNs during pregnancy. Hill et al. [
30] systematically examined both supply and demand factors associated with low IPTp uptake and low ITN use. In some countries, poorer women, those with no education, or those living in rural areas were significantly less likely to receive IPTp [
35].
The use of health survey data can be a powerful tool to inform where challenges remain in current prevention strategies. However, the findings may not be generalizable to all of Senegal. First, the variable used to assess use of ITNs during pregnancy was the self-reported sleeping under an ITN (and not during pregnancy, but the night prior to the survey, with the assumption being that this would be the same as during pregnancy). Some women may be tempted to overestimate their bed-net use as pregnancy is a sensitive issue [
34]. Alternatively, this phrasing in the DH survey question could result in misclassification bias as it is possible that women used ITNs during pregnancy, but did not use them the night prior to the survey. Secondly, IPTp administration was assessed only for the proportion of women who had a live birth within the 2 years preceding the survey. Therefore, women with interrupted pregnancy, without a live birth, or women who were pregnant at the time of the survey were not included in the analysis. Thus, there might be a potential for selection bias and the results may not be fully representative of the population of pregnant women in Senegal. However, even with these limitations, the analysis of National Survey Data provides important insights into the factors influencing uptake of malaria prevention methods and can be useful in guiding policy implementation strategies.
Authors’ contributions
MASM conceived the study, obtained permission to download the dataset, designed the study, analyzed the data wrote the manuscript. AKB, AM participated in drafting the manuscript, assisted with interpreting the data analysis and wrote the manuscript. AA provided substantial contribution to the design and interpretation of data and revised the draft manuscript. MS, SM has made contribution to the design and interpretation of data and revised critically the draft manuscript. SM has made substantial contributions to conception and design, revised critically the manuscript and supervised the research. OG has made contribution to the design and interpretation of data and revised critically the draft manuscript and supervised the research. All authors read and approved the final manuscript.